Finding the right approach to EPT

Physician groups and public health authorities have advocated on behalf of expedited partner therapy, a practice that bypasses the traditional patient-physician relationship. A member of the AMA Council on Ethical and Judicial Affairs discusses the ethical pros and cons and why the AMA recommends EPT, within suggested limits.

Reply: Expedited partner therapy, as defined by the Centers for Disease Control and Prevention, is "the practice of treating sex partners of patients with sexually transmitted diseases without an intervening medical evaluation or professional prevention counseling."

In other words, when a heterosexual adult is seen and diagnosed with gonorrhea or chlamydiosis, he or she is given antibiotic treatment and also a prescription for his/her partner(s). This practice raises ethical concerns.

EPT involves writing a prescription for a patient diagnosed with gonorrhea or chlamydiosis and also a prescription for a partner who is possibly infected, but whom the physician has not seen. The second prescription (accompanied by information) is given to the patient in the health care setting to pass on to his/her sex partner, a practice known as patient-delivered partner therapy.

Evidence supporting the efficacy of EPT comes from four randomized clinical trials that compared EPT with standard treatments for trichomoniasis, chlamydiosis and gonorrhea. Overall, the reinfection rates for chlamydiosis and gonorrhea were lowered significantly through the use of EPT.

The researchers also found EPT to be cheaper and thereby more cost-effective than other standard STD treatments. EPT is also considerably easier for physicians and requires far less time than does standard management of patients' possibly infected partners.

Current research does not offer guidance for patients younger than 18 and does not recommend EPT for men who have sex with men. Because there was no evidence that EPT increased successful treatment of trichomoniasis, the CDC recommends for now that EPT be limited to heterosexual couples who are suspected to have gonorrhea and chlamydiosis.

EPT is not without flaws. Some of the clinical barriers to success of the treatment are significant.

If a patient's partner has chlamydiosis, gonorrhea or both, then EPT should prove effective. If, however, a female partner has pelvic inflammatory disease, she will need additional treatment beyond what EPT offers.

Second, EPT does not cover concomitant incidents of syphilis, HIV or trichomoniasis. The CDC recommends that EPT prescriptions given to a patient be accompanied by material that explains these diseases and lists resources to help partners locate a physician for further treatment if needed.

Third, patients are not asked about their partners' medication and food allergies or about concurrent medications that can be counterindications for EPT use. Consider, for example, a young woman taking oral contraceptives. Her partner is treated for chlamydiosis and is given an extra doxycycline prescription. The woman takes the doxycyclin with her oral contraceptives, continues to be sexually active, and becomes pregnant due to the interaction between the two medications.

The legality of EPT varies from state to state. It is permitted in 15 states and in Baltimore, and is expressly prohibited in 11 states. Twenty-four states do not expressly permit or prohibit it. Clinical validation does not change its legal status. In the 11 states where EPT is illegal, physicians may face legal consequences for using it.

Principle VII of the AMA's Principles of Medical Ethics states, "A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health." Because EPT decreases the reinfection rate for the most common STDs, its use contributes to the betterment of public health.

But that alone is not enough. It must be demonstrated that this benefit is not offset by possible harms, and, unfortunately, relying upon EPT as the initial or primary therapeutic option does not serve all partners well.

Patient-delivered partner therapy requires that physicians write prescriptions for individuals they have never seen. EPT abrogates the patient-physician relationship by eliminating the traditional physical encounter between a physician and a patient.

When handed a prescription and reading materials about STDs, the patient's sexual partner is not able to discuss questions or concerns about diagnosis or therapy with the treating physician, hence the informed consent process is preempted. The sexual partner depends on the original patient (typically a layperson) to inform his or her decision-making and to explain the appropriate way to take the prescribed medication.

Patient-delivered partner therapy necessarily entails a breach of confidentiality, but any treatment of patients with STDs and their partners necessitates loss of confidentiality, whether the patient notifies the partner or the partner is notified by the health department.

Because of the aforementioned concerns, but keeping in mind that EPT is a valuable tool in the armamentarium of physicians treating STDs, the AMA's Council on Ethics and Judicial Affairs wrote an opinion on the practice.

EPT should only be used, the opinion states, if the treating physician believes that the patient's partner(s) is (are) unwilling or unable to seek treatment within the context of a traditional patient-doctor relationship. Before writing the second prescription, physicians should speak to public health officials and legal officials to determine the legal status of EPT in their states and communities.

When EPT is proffered as treatment, it always should be accompanied with written material that covers allergy information, common questions and answers, and signs and symptoms of concomitant diagnoses.

All partners should be referred to physicians or clinics for official testing and follow-up.

They all need information about trichomoniasis, HIV, syphilis, and potential drug interactions. All female partners need to verify that they are not pregnant before beginning EPT, and women in particular need information about the potential for pelvic inflammatory disease.

In conclusion, there is no reason that EPT, used responsibly when traditional tools are unlikely to be efficacious, cannot augment physicians' tools in the fight against STDs.

It is estimated that most practitioners tell infected patients that they should notify their partners, but that only 4% actually gather information about the partner for the health department's traditional partner-notification program. This leaves a tremendous number of partners relying upon the patient for notification, and, in the past, only a small percentage of patients actually followed through with partner notification. There is good evidence that EPT is increasing that percentage.

Physicians who wish to prescribe EPT should seek the advice of public health officials and legal counsel, be certain that accurate information accompanies the additional EPT prescription, and make every effort to follow up with the patient to ensure that his or her partner received the necessary treatment and care.

Hilary E. Fairbrother, MD, resident in emergency medicine, New York Methodist Hospital; member, AMA Council on Ethical and Judicial Affairs